Delay in Laboratory Specimen Pickup Resulting in Untimely UTI Diagnosis
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who was experiencing symptoms suggestive of a urinary tract infection (UTI). The resident, who had a history of confusion, increased urinary frequency, abdominal cramping, and pain during urination, had a urine specimen collected for urinalysis and culture as ordered by a nurse practitioner. Despite the specimen being collected promptly, there was a delay in its pickup, as the laboratory did not retrieve the specimen for processing until two days after collection. Interviews with the Director of Nursing confirmed that the facility's standard procedure was for lab specimens to be picked up daily on weekdays, with the option for a stat pickup on weekends if needed. The Director acknowledged that there should not have been a delay between specimen collection and delivery to the lab. Additionally, the facility's policy on laboratory and diagnostic guidelines did not specify timeframes for collection, transportation, or reporting of lab results, contributing to the lack of timely laboratory services.
Plan Of Correction
Element 1: Resident R904 no longer resides in the facility. Element 2: All current residents identified with labs and diagnostic tests ordered over the last 14 days were verified as completed. Any concerns were immediately addressed. Completed by the Director of Nursing / designee on 5/7/2025. Root Cause: Facility failed to ensure timely follow up for lab services. Element 3: The Laboratory and Diagnostic Guidelines Policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The Director of Nursing / Designee has re-educated all current licensed nurses on the Laboratory and Diagnostic Guidelines Policy by 5/19/2025. Any current licensed nurse not re-educated by 5/19/2025 will be re-educated prior to their next scheduled shift. Nurse managers will review the order listing report daily, Monday through Friday, in morning clinical meeting to ensure labs and diagnostics are completed as ordered. Element 4: The Director of Nursing / Designee will audit the order listing report daily, Monday through Friday, to ensure labs are completed as ordered. Audits will continue for 5 days per week x4 weeks and then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Administrator is responsible to maintain compliance.